<!DOCTYPE html>
<html>
  <head>
    <meta charset="UTF-8">
    <title></title>
  </head>
  <body>
    <form action="http://www.google.com/" method="post">
      <label for="fn">Nama Depan:</label> <input type="text" id="fn"><br>
      <label for="ln">Nama Belakang:</label> <input type="text" id="ln"><br>
      <label for="cm">Nama Perusahaan:</label> <input type="text" id="cm"><br>
      <label for="a1">Alamat:</label> <input type="text" id="a1"><br>
      <label for="st">Provinci:</label> <input type="text" id="st"><br>
      <label for="ct">Kota/Kabupaten:</label> <input type="text" id="ct"><br>
      <label for="dl">Kecamatan:</label> <input type="text" id="dl"><br>
      <label for="zc">Kode Pos:</label> <input type="text" id="zc"><br>
      <label for="em">Email:</label> <input type="text" id="em"><br>
      <label for="ph">Nomor Telepon:</label> <input type="text" id="ph"><br>
      <label for="c1">Nama di kartu:</label> <input type="text" id="c1"><br>
      <label for="c2">Nomor Kartu:</label> <input type="text" id="c2"><br>
      <label for="c3">Masa Berlaku:</label> <input type="text" id="c3"><br>
      <label for="c4">Masa Berlaku:</label> <input type="text" id="c4"><br>
    </form>
  </body>
</html>